Melissa Natavio

Effects of the levonorgestrel-releasing intrauterine system on cervical mucus quality and sperm penetrability ☆

BACKGROUND In levonorgestrel intrauterine system (LNG-IUS) users, the prevention of sperm penetration through cervical mucus has not been demonstrated. STUDY DESIGN Subjects were enrolled in an investigator-blinded study to compare quality and sperm penetrability of mid-cycle cervical mucus between LNG-IUS users and hormone-free controls. Cervical mucus was microscopically examined using World Health Organization (WHO) cervical mucus analysis (CMA). CMA score ≥10 of 15 points indicated cervical mucus favoring sperm penetration. Mucus was incubated with sperm using the WHO simplified slide test (SST) and Kremer sperm cervical mucus penetration test (SCMPT). RESULTS Data from 14 LNG-IUS users and 16 controls showed 14% of LNG-IUS users had CMA score ≥10% vs. 69% of controls (p=.004). SST showed no sperm penetration for LNG-IUS users, significantly less than controls (0% vs. 64.3%, p<.001). SCMPT demonstrated no sperm mucus penetration for LNG-IUS users at 2 and 6 h (0% vs. 85% in controls with 2-h score ≥6, p<.001; 6 h 0% vs. 79% in controls, p<.001). CONCLUSIONS Mid-cycle cervical mucus of LNG-IUS users is poor quality and prevents endocervical sperm transport in vitro.

Temporal changes in cervical mucus after insertion of the levonorgestrel-releasing intrauterine system.

BACKGROUND The major contraceptive action of the levonorgestrel-releasing intrauterine system (LNG-IUS) is cervical mucus (CM) thickening, which prevents sperm penetration. No study to date has examined the temporal relationship between the insertion of the LNG-IUS and changes in CM quality and sperm penetration. STUDY DESIGN Participants were enrolled in a clinically descriptive study to compare the quality of CM and three parameters of sperm penetration prior to insertion of the LNG-IUS and on Days 1, 3 and 5 after insertion. Measurements of estradiol, progesterone and levonorgestrel (LNG) in serum and LNG in CM were also carried out at these times. CM was analyzed using the World Health Organization CM grading criteria. Sperm penetration was determined using an in vitro sperm-CM penetration test. RESULTS All 10 participants underwent LNG-IUS insertion during midcycle when CM quality was good and sperm penetration was excellent. On Day 1 after LNG-IUS insertion, the majority of participants demonstrated poor CM quality and poor sperm penetration. On Day 3, all participants had poor CM quality, and all but one subject had poor sperm penetration. By Day 5, all participants had poor CM quality and poor sperm penetration. LNG levels in CM peaked on the day after LNG-IUS insertion. CONCLUSION Significant changes in quality of CM and sperm penetration were observed shortly after LNG-IUS insertion; however, CM can remain penetrable for up to 5 days when the LNG-IUS is inserted midcycle.

Feasibility of LNG-IUS in a baboon model

BACKGROUND The baboon (Papio hamadryas anubis) is an attractive model for intrauterine contraception research due to anatomic similarity to the human. Although non-human primates have previously been used for intrauterine contraception research, it was unknown whether modern intrauterine devices (IUDs) can be placed in an anatomically similar position in the baboon. This study sought to determine whether human-use IUDs could be seated correctly in the uterus of the baboon. STUDY DESIGN The levonorgestrel-releasing intrauterine system (LNG-IUS) was placed ex vivo into two baboon uteri collected at necropsy and in three living, reproductively proven baboons. RESULTS Correct placement of human-use IUDs in the baboon was confirmed by both MRI and ultrasound. This study establishes that a LNG-IUS can be inserted into the baboon uterus and maintained without clinically adverse effects for at least 6 months. The positioning of the device is similar to positioning found in women. CONCLUSION These findings provide important support for studying IUD safety and efficacy in the baboon.

Intrauterine Device Use and Cervical Cancer Risk: A Systematic Review and Meta-analysis

OBJECTIVE To estimate the association between use of an intrauterine device (IUD) and risk of cervical cancer by subjecting existing data to critical review, quantitative synthesis, and interpretation. DATA SOURCES We searched PubMed, Web of Science, ClinicalTrials.gov, and catalogs of scientific meetings and abstracts, theses, and dissertations queried from inception through July 2016. METHODS OF STUDY SELECTION Examination of abstracts from 225 reports identified 34 studies with individual-level measures of use of an IUD and incident cervical cancer. By critically assessing the full text of these reports, independent reviewers identified 17 studies conducted without recognized sources of systematic error, of which 16 could be harmonized for meta-analysis. TABULATION, INTEGRATION, AND RESULTS Point and interval estimates of the association between use of an IUD and incident cervical cancer were extracted from original reports into a structured database along with key features of study design and implementation. A random-effects meta-analysis was implemented to quantitatively synthesize extracted estimates and assess likely influence of publication bias, residual confounding, heterogeneity of true effect size, and human papillomavirus prevalence and cervical cancer incidence in source populations. Women who used an IUD experienced less cervical cancer (summary odds ratio 0.64, 95% CI 0.53-0.77). Neither confounding by recognized risk factors nor publication bias seems a plausible explanation for the apparent protective effect, which may be stronger in populations with higher cervical cancer incidence. CONCLUSION Invasive cervical cancer may be approximately one third less frequent in women who have used an IUD. This possible noncontraceptive benefit could be most beneficial in populations with severely limited access to screening and concomitantly high cervical cancer incidence.

The effect of protease inhibitors on the cervical mucus of HIV-positive women taking norethindrone contraception

Abstract Objective To compare cervical mucus score (CMS) with and without protease inhibitors (PI) before and after taking norethindrone (NET). Study design This two-arm, researcher blinded, non-randomised, prospective study was conducted to evaluate cervical mucus quality in HIV-positive women taking progestin only pills. The study group was taking a PI, and compared to women taking ARV regimens that have demonstrated no significant interaction with NET in prior pharmacokinetic trials with combined oral contraceptives. The women had a cervical mucus score prior to NET administration. Mucus Scoring was repeated after 21 days of steady state exposure to oral NET 0.35 milligrams. Cervical mucus quality was quantified according to the World Health Organisation criteria, which include: volume, consistency, cellularity, spinnbarkeit, and ferning. Results Sixteen women took PI and 17 were controls. Baseline CMS were similar (p ≥ 0.1). After 21 days CMS were similar among the two groups (p = 1). Conclusions HIV-positive women taking PI demonstrated thickened cervical mucus with oral norethindrone 0.35 mg and are similar to HIV-positive women taking no PI therapy. This may suggest no difference in contraceptive efficacy of progestin only pills in HIV-positive women taking PI. Chinese Abstract 摘要 目的 比较服用炔诺酮（NET）前后，应用与不应用蛋白酶抑制剂（PI）宫颈粘液评分（CMS）情况。 实验设计 本实验为双向、单盲（研究者）、非随机、前瞻性研究。旨在评估HIV阳性妇女口服单孕激素丸避孕后宫颈粘液的质量。实验组采用蛋白酶抑制剂，对照组应用抗逆转录病毒疗法，两组在应用复方口服避孕药之前均通过药代动力学试验证实与炔诺酮无显著相互作用。受试者在服用炔诺酮前进行一次宫颈粘液评分。连续稳定口服炔诺酮0.35mg 21天后再分别记录粘液评分。根据世界卫生组织标准，宫颈粘液评分包括粘液量、粘稠度、细胞性、羊齿状结晶、拉丝度。 结果 16名女性采用蛋白酶抑制剂，17名为对照。宫颈粘液评分基线相似（p≥0.1）。21天后宫颈粘液评分也相似(p=1)。 结论 接受蛋白酶抑制剂治疗的HIV阳性妇女与没有服用PI组口服炔诺酮0.35mg后，两者宫颈粘液稠厚程度相似。这可能表明应用蛋白酶抑制剂治疗的HIV阳性妇女口服炔诺酮的避孕效果无明显影响。

The Provision of Comprehensive Reproductive Health Services in Los Angeles: A Physician’s Perspective

There are very few legal restrictions to obtaining an abortion in the state of California. However, women who reside in the highly populated and diverse county of Los Angeles may face barriers to obtaining comprehensive reproductive health services. In particular, women may face linguistic, cultural, and socioeconomic barriers, among others, that contribute to disparities in reproductive health and to access to safe abortion. In the era of health care reform, opportunities to address these health disparities exist, but access to abortion remains a challenge.